A man with a lot on his mind

For over two years, Joe (definitely not his real name!) was waiting for someone to tell him that his pain could be cured, or not. One way or another he’d have liked to know. In the meantime he looked everywhere for things to fix his pain.

He’d, in his words ‘smashed’ his hand up in a crush injury, and developed what seemed to be complex regional pain syndrome in his non-dominant hand, which would have been fine if he had a pen and paper job. Joe didn’t, he worked as a joiner, a craftsman. What’s worse, he was self-employed, and during that two years his business went under, and his future as a skilled craftsman looked bleak.

Yes, he had compensation – 80% of the income he’d declared for tax purposes, which was nothing like what he’d actually made because much of his income had been plowed back into his business. And with compensation came a whole lot of requirements: to attend various people for assessments (he worked out he’d had 9 different assessments just for the medical or treatment part of his rehabilitation, a further 4 for vocational rehabilitation, and several for necessary equipment and support for home); to attend treatments (none of which had resolved his pain); to tell people about his distress and worries about his future; his life which had been very private, was now an open book to more people than he wanted to think.

Joe was asked to see me because he had refused to consider any of the options that his vocational assessment had come up with, and because when he had started to think about work, he became depressed and anxious. He told me he threw the vocational assessment in the bin because the suggestions were, in his words, ‘insulting’. He told me the assessor had no idea what a craftsman joiner actually did, and the list of potential jobs included ‘retail assistant’, ‘carpenter’, ‘builder’, ‘courier driver’.

When I reviewed the concerns Joe had about work, it’s no wonder he was stressed. I used a work self efficacy assessment to identify the areas he felt confident about, and those he didn’t. The areas he felt fine about were his ability to work out ways to keep himself safe at work, to let people know what he needed, and to be ‘a good employee’ – but he had very low confidence in these areas:
(1) ability to work a full day
(2) ability to meet quality requirements
(3) ability to tell others about his pain
(4) ability to obtain support and assistance from others
(5) ability to work in a way that used his skills

He told me the work was important because ‘it is who I am’. And who he was was a very capable, highly skilled man with an 18 year history of work as a joiner who produced quality goods that he could be proud of. He said he felt ashamed of his pain, and that he couldn’t be a ‘real man’ because his pain hadn’t resolved. And what’s more, he felt frustrated that the job options he’d been given were of such a low skill level. He’d put a huge investment of himself and his time and energy to develop a high level of technical skill into being a hands-on craftsman.

A couple of interesting things about this case – first of all, although details have been changed, this is a real situation. His angst is real, and his concerns about his future – and his response to his situation – are real.

He’d waited two years to hear that his pain was either going to go, or not. No-one had been clear with him that pain can become chronic, and that this is neither a death sentence, nor a life sentence. Life is possible with persistent pain. Instead he’d been held in stasis for that time, being uncertain which way to turn, and consequently he lost his business. Once he’d received the diagnosis and prognosis, he was able to confront his future – and yes, admittedly for a while he has become very distressed, but he told me that at last he could make clear choices.

What do we learn from that? Don’t fudge! If the chances of pain resolving are slim, let the person know so they can start to live.

The second point is that work is so much more than a way to earn a living.
I don’t know whether this particularly applies to men, but it certainly applies to tradesmen – their work is part of their identity, it carries more emotional significance than the pay-packet, it represents years of skill development, and no, suggesting that someone like this consider a job that is a step down is just not going to sit well!
I don’t know whether Joe will return to his previous work. He won’t be able to return to his business.

I do know that he now has a sense of hope as I’ve started to help him review his situation and see that what he views as a liability (ie his functional limitations) can be turned into an asset – he’s much more likely to be careful, safety-conscious, and efficient at his work because it matters to him if he hurts himself.

It will be a long road for Joe, he has a lot of pain management to develop, as well as addressing his lack of confidence and the mismatch between his expectations of himself and his current abilities. But this is pain management at the coalface – this is what I love.

Return to work: Clinical judgements and evidence-based decisions


It’s not often that we find an article that draws on clinical knowledge rather than directly from experimental findings, but when we do, it can add something really helpful as in this article by Heidi Muenchberger, Elizabeth Kendall, Peter Grimbeek and Travis Gee.

Now I’m definitely a proponent of evidence-based management – but in very complex situations such as the return to work setting, the insights gained from our clinical experience can be very helpful.

What these researchers did was review the literature on factors known to be associated with returning to work for people experiencing musculoskeletal injury. From an initial group of over 1000 articles, only 55 met their inclusion criteria, which is surprising in some ways, and could suggest that perhaps they were rather too restrictive in their choices. Despite this, 38 unique predictors were identified, which were expanded by a group of researchers to a total of 85. Some of the predictors that were expanded included: Dependents, Occupation, Employment status, Nature of injury etc.

The authors of this report commented that, as in many meta-analytic studies, many of the terms used were rather loosely defined and could cover a multitude of factors. For example, ‘rehabilitation intervention’ ranged from medical treatment, physical rehabilitation, educational rehabilitation, multidisciplinary rehabilitation, vocational rehabilitation… ahh do you get the picture?!

A separate group of rehabilitation practitioners were then brought in to participate in the clinical examination of the relevant factors. From a large number of individuals, only 12 participants completed the study, and sadly there were no occupational therapists (in New Zealand, occupational therapists and physiotherapists appear roughly in equal numbers providing vocational rehabilitation).

This groups’ job was to rate each of the 85 predictors using three scales according to importance, modifiability and categorisation. Importance and modifiability were rated using a three-point scale, while they were asked to classify each predictor according to a seven-point nominal scale, with ‘each value representing one of seven categories of the typology proposed by Krause and colleagues’
1 = Individual Worker Factors,
2 = Injury Factors,
3 = Medical and Vocational Rehabilitation Factors,
4 = Job Factors,
5 = Organisational Factors,
6 = Insurer Factors
7 = System Factors
The most useful aspect of this study probably also took the most time: ‘practitioners were asked to provide a written rationale for each of their 85 ratings of importance. Specifically, participants were asked to describe why each predictor was important for rehabilitation and how it influenced return-to-work. This qualitative data was analysed separately to the survey results.’

And the findings?
Well, I was interested in just how much agreement there was between practitioners – and it came out as ‘fair’ (Kendall tau = 0.27). Curiously, the authors suggest that this is ‘acceptable’, but in my mind it’s probably a little low…Despite this, the results of internal reliability testing at the individual predictor level showed that practitioners were in agreement for importance of predictor. Only four predictors were considered the most important to rehabilitation and return-to-work by almost all practitioners (over 90%). These were:

  • timeliness of rehabilitation,
  • clear return-to-work goals,
  • communication between GPs and injured workers and
  • rehabilitation in the workplace

‘Predictors that were considered least important to rehabilitation included gender, cultural background and whether the person was a member of the union. Interestingly, some of these predictors (e.g., gender, cultural background) are among those represented most frequently in the return-to-work literature.’

What can we make of this discrepancy? Well with the small reference group, not a lot really. What would be interesting would be to see what other groups such as employers or people undergoing rehabilitation would say!

Two predictors, namely ergonomic strategies within the workplace and timeliness of rehabilitation,
were agreed by most (at least 80%) practitioners as having the greatest possibility for modification.
I’m not sure that the first, ergonomic strategies, is particularly helpful especially for the long term management of a musculoskeletal problem, however, it’s nice to know that practitioners acknowledge that they’re relatively easy to modify – perhaps that ease of modification (and the visibility of modifications) is why they get done, while other aspects such as timeliness and communication do not.

Judgements of clinical utility were made using ratings of importance and modifiability (is that even a word?!). Nine factors were identified as having sufficient agreement:

  • Rehabilitation in the workplace
  • GP and injured worker communication
  • Clear return-to-work goals
  • Timeliness of rehabilitation
  • Proactive response by employer
  • Workplace accommodations
  • Elimination of risk factor from workplace
  • Modified work
  • Intensity of rehabilitation

Cultural factors were commented upon by the research group: ‘‘injured workers from
non-English speaking backgrounds often have cultural pressures on them not to complain or to keep
working even if injured’’, and, ‘‘some cultures have a particularly strong work ethic and other cultures (on the whole) cope less well with the change an injury brings, which deeply affects their pride and their ability to be the breadwinner’’.

To accommodate this, the authors state that ‘culture was more likely to be inherently considered in the design of intervention rather than as a single predictor of outcome.’

I’m not entirely sure how this was determined from this piece of research – and indeed, I’m not sure whether it is well considered. Perhaps this is yet another area for research from the patient’s perspective.

I’m going to continue commenting on this study tomorrow – the qualitative comments provide some interesting findings, and deserve more space than I can give today!
So, come on back tomorrow for more!!

Muenchberger, H., Kendall, E., Grimbeek, P., Gee, T. (2007). Clinical Utility of Predictors of Return-to-work Outcome Following Work-related Musculoskeletal Injury. Journal of Occupational Rehabilitation DOI: 10.1007/s10926-007-9113-0

Krause N, Frank JW, Dasinger LK, Sullivan TJ, Sinclair
SJ. Determinants of duration of disability and returnto-
work after work-related injury and illness: Challenges
for future research. Am J Ind Med 2001;40(4):464–84.

Work and disability

It’s taken me some months to finally put something down about my favourite topic – work! I’m a fervent believer in the value of work as an incredibly important component of life, and one of the really telling ways to identify whether pain management skills have become embedded in the coping repertoire of an individual.

A model of work disability that I’ve found useful is based on Lent, Brown and Hackett’s social cognitive career theory, which is in turn based on Bandura’s work on motivation. This model suggests that people determine their work options based on self efficacy, outcome expectations and personal goals. Self efficacy is, in turn, based on personal performance and accomplishments; vicarious learning; social persuasion; and physiological and affective states. Outcome expectations are beliefs about the outcome of various behaviours, and personal goals are the determination to engage in a particular behaviour or achieve a certain outcome. In addition to these core areas, interests and values and contextual conditions influence opportunities and choice.

As a result of disability, individuals belief in their own self efficacy, and outcome expectations are changed. Many people find previous performance and accomplishments no longer count, anxiety about performance, as well as outcome expectations that they are ‘no longer reliable’ mean that they feel anxious about seeking work. Given the lack of knowledge about self that most teens have when choosing a career, it’s not surprising that people who experience work disability have a great deal of trouble identifying exactly what they can offer an employer.

Some of the basic predictions of the SCCT are: Some people eliminate possible occupations due to faulty self efficacy beliefs or outcome expectations, especially when they experience changed ability to perform tasks, without appropriate ways to test their strengths.
The greater the perceived barriers to an occupation, the less likely individuals are to pursue those careers So, if they’ve never been job seeking, they have trouble managing their home-based responsibilities, and there are no role models with disabilities in their employment history, it’s very difficult for them to consider a new work option.
Modifying faulty self efficacy and outcome expectations can help individuals acquire new successful experiences and open their eyes to new career occupations – and this is the work of a vocational specialist counsellor.

In our work as therapists, we all encounter situations in which we are directly or indirectly influencing the work choices of someone with a disability. It may be helpful to remind both ourselves and the person we’re working with that although their function may have changed in some domains, the majority of domains remain unchanged despite pain. So, although self efficacy for ‘lifting heavy things’ or ‘working physically’ may be changed due to poor biomechanics and difficulty tolerating increased pain, this doesn’t affect the global ability to ‘be a good worker’. We may need to support the person to become much more aware of their work style, and particularly their beliefs about what constitutes ‘a good worker’ – if their belief that ‘a good worker’ depends on ‘working 100% and not taking any breaks’, this will conflict with our suggestion that they break a task up into time contingent quota, and we may need to help them consider that ‘good workers’ come in many flavours!

Career decision-making tasks include evaluating career-related abilities and skills, gathering occupational information, selecting occupational goals, and making plans to implement a career goal (Betz & Taylor, 2001). Thus, career self-efficacy reflects an individual’s confidence in performing a self-evaluation, gathering occupational information, selecting a goal, and making implementation plans. We can help with each of these four areas within our therapy, by providing accurate self-evaluation, ensuring occupational information is gathered from as broad a range of job options as possible, helping realistc goal-setting to occur, and ensuring implementation plans are supported and monitored.

Helping people return to productive lives is an integral part of pain management – and one I hope we all can be part of.

Bandura, A. (1997). Self-efficacy: The exercise of control. New York: W. H. Freeman.

Lent, R. W., Hackett, G., & Brown, S. D. (1996) A social cognitive framework for studying career choice and transition to work. Journal of Vocational Education Research, 21(4), 3-31.

Back to work with pain

At last, something dear to my heart hits the news!

I dropped into MedWorm and skimmed the headlines just a moment or two ago, and found this!!!

It was entitled ‘Hope for low back pain sufferers’ and initially my heart sank – not another ‘we can fix you’ article promising much relief from pain but possibly not delivering it… And then I read on.

Now medical research charity the Arthritis Research Campaign has awarded a three-year primary care fellowship of almost £132,000 to occupational therapist Carol Coole at The University of Nottingham, to develop more effective ways in which the NHS can work with employees with back pain – and their employers – to ensure that back pain doesn’t drive them away from the workplace.

Being able to remain working is of critical importance to everyone involved in the experience of back pain – the person with pain who doesn’t want to lose his or her job, and at the same time doesn’t want to suffer from their pain; the employer who doesn’t want to lose productivity or face the costs of finding a new employee; the health care funder who doesn’t want to have to spend huge amounts of money on treatments only to find that the outcomes just aren’t there (the longer someone stays off work, the longer they are likely to continue to stay off work); and finally, for health care providers who really don’t want to continue to have a person fronting up for help for their back pain without adequate supports that they can be referred to.

In 1995, at Burwood Hospital, Christchurch, I developed a pain management programme specifically to help people who wanted to return to work despite having ongoing pain. Despite various changes and the eventual demise of that particular programme (WorkAbilities), the specific focus on integration of vocational issues within pain management has been a theme at Burwood Hospital Pain Management Centre ever since. It’s absolutely vital that people who experience pain are given every support to help them return to normal life roles including work – better for health, better for quality of life, and better economically.

I’ll be writing more on this over time, but for now it’s GREAT to see that a significant research award has been given to an occupational therapist to address this compelling issue. I hope that many more health providers will consider how important generalising the use of pain management skills to all situations including work can be to people with chronic pain.

Congratulations to Nottingham University and Carol Coole – way to go!!